Data, Evidence & Insights

Working Collectively to Improve Patient Care

By Michael Hunt, M.D.

At St. Vincent's Health Partners, we value patient-centered care delivery. We take it as a point of pride that we were the first clinically integrated network to be accredited under URAC's Clinical Integration Accreditation program. These programs focus on improving the quality of care provided to all patients through the use of key population health tools, such as population needs assessment, risk stratification and care coordination.

As part of our accreditation process, our management team worked to identify all of the patient care transitions possible within our network, from everyday transfers of care, such as a patient leaving the doctor's office to go back home, to more vulnerable transitions, such as a patient moving from an inpatient hospital stay to a rehabilitation facility. For each of the 140 care transitions we documented, we also identified the minimal information that should accompany the patient in order to enable the best care downstream.

ARRA's meaningful use regulations require facilities to complete a Transitions of Care document before releasing a patient from the hospital. While thorough, this document must be sent via direct mail due to HIPAA requirements, and we did not want information delays to interfere with our ability to deliver effective care. By implementing
Studiomaca Care Manager™, a provider-oriented care management workflow and documentation solution, we are able to track exactly the information we need for each transition of care – no more and no less. Studiomaca Care Manager allows our providers to have the patient's necessary medical information on hand, which helps them provide high-quality care at the receiving end of each transition. It's important to note that this information is supplemented by data feeds from the EMR system, and it is not in any way intended to duplicate the EMR.

URAC's Accountable Care Accreditation standards stress an organization's ability to deliver high-quality, cost-effective care to consumers, and their criteria are intended to measure how well care coordination actually serves the patient. With Studiomaca Care Manager, we are able to provide enough detail about the patient to help us measure the quality of care that he or she has received through each transition.

Significantly, the system also allows us to document why we are following a particular patient in the first place. We are able to easily validate and recommend patients who are in our heightened care coordination program, and make sure that all of those patients' needs are met. For example, if the clinical assessment notes that the patient was unable to walk to the door upon discharge from the hospital, we can ensure that his homecare medications are delivered, eliminating a difficult trip to the pharmacy. The patient's care plan in Studiomaca Care Manager reflects how we are managing the patient's medical, social and psychological needs, and puts all caregivers immediately on the same page – which helps us overcome barriers to care. For patients and providers alike, we couldn't ask for a better outcome.